This questionnaire is intended for everyone who visits our practice location(s) IN PERSON and needs to completed for each 24 hour period. It applies if you are either the patient or if you are accompanying a patient. We thank you for taking the extra time to help us maintain a COVID free healthcare workplace.

A valid mobile phone number OR email is required below in case we have to alert you. You will be sent a code to validate the information entered.

Mobile Phone

Email Address

Screening Questions
*

Yes

No

Cough, Sore throat, shortness of breath, fatigue

Fever > 100 degrees

Diarrhea

Loss of taste or smell

Dizziness or loss of balance

Have you tested positive for COVID-19

Traveled internationally within the last 21 days

Traveled domestically to COVID hot zone 21 days

Have anyone sick at home

Been exposed to anyone with COVID-19

Positive Symptoms

I attest that the above information is accurate to the best of my knowledge.

If I develop any of the above symptoms or turn COVID-19 positive in the next 14 days, I will contact STARS Plastic Surgery at 210-201-2806. I am aware that for today's visit, that I will need to wear a mask and as a patient, will have no more than ONE NECESSARY companion. Children under 14 not allowed unless he or she is the patient.